Evaluation of antibiotics resistance in Southern Iran in light of COVID‐19 pandemic: A retrospective observational study

Abstract Background and Aims Antimicrobial resistance (AMR) was taken as one of the high‐priority long‐lasting public health issues, although it might have been underrated in terms of COVID‐19 pandemic emergence. Regarding limited data on assessing the pandemic effect on AMR trend in Iran, this study aimed to describe the epidemiology of antibiotics resistance during the COVID pandemic in southern Iran. Methods This descriptive study was conducted on 2675 patients' samples collected and processed in a referral COVID‐19 center hospital in southern Iran from March 21, 2019, to February 18, 2020 (prepandemic), and February 19, 2020, to March 21, 2021 (pandemic). Susceptibility test results in sensitivity and resistance levels were compared in prepandemic and pandemic periods. Results Compared to prepandemic, the inpatient number has increased almost three times. On the other hand, there are around four times fewer outpatients now. More than 85% of the specimens were found in urine samples. In all, 92.22% of all bacteria samples were Gram‐negative isolates, with Escherichia coli accounting for 59.19% of them. The change rate of Gram‐negative bacteria resistance to antimicrobials is an average of 7.74% (p < 0.001). On the other hand, the average change rate of Gram‐positive bacteria resistant to antibiotics has decreased by 19.3% (p = 008). As a forerunner among other Gram‐negative bacteria, the average change rate for Pseudomonas aeruginosa and Klebsiella pneumonia resistance to monitored antibiotics was 89% and 66.3%, respectively (p < 0.001). Conclusion During the Covid‐19 pandemic, the increase in AMR among Gram‐negative bacteria, particularly P. aeruginosa and K. pneumonia, was observed compared to the prepandemic. This further limits treatment options, and endangers global public health.


| INTRODUCTION
Antimicrobial resistance (AMR), as one of the most critical worldwide public health issues, should be intercepted as soon as possible. 1 AMR affects health care, and life quality eventuating in death and extra cost. 2 If there are no interventions, it was estimated that the annual death rate will reach 10 million in 2050 caused by AMR. 3 Considering the pathogen's resistance does not have any geographical boundary, AMR must not be taken as a bordered problem for just some countries or regions regarding either income or level of development. 4 In 2017, World Health Organization listed some high priority, and critical bacteria most of which belonged to Gram-negative bacteria.
These pathogens have multidrug-resistant features and cause healthcare-associated infections. 5 The COVID-19 pandemic as a parallel issue to AMR is taken as a crucial health emergency. It is an acute problem; on the other hand, the AMR is the long-lasting one. 6 Some comparative studies on AMR rates during COVID-19 and before the pandemic has disclosed a significant change. [7][8][9][10][11] Taking action to slow down the spread of COVID-19, such as social distancing, using physical barriers, and so forth, has led to a reduction in the spread of other infections, which resulted in less usage of antimicrobials. Hence, it was reported that patients with other infections prefer not to seek care in healthcare centers. [12][13][14] On the other hand, researchers empirically reused some medications, including some antibiotics, regarding their antiviral effects, to treat COVID-19 patients, disregarding antimicrobial stewardship rules. 5,[12][13][14] For instance, azithromycin was prescribed to treat SARS-CoV-2. If their usage has not had any significant effect on treating COVID-19, this matter has not had any consequence, but the AMR increased. 9 The bacterial co-infection with COVID-19 has increased the rate of antibiotic prescription in hospitalized patients, but there are no data on community antibiotic usage. [15][16][17] The mutual effect of AMR and COVID-19 is unknown yet. 6 This study aimed to describe the epidemiology of antibiotics resistance in Jahrom District, Southern Iran during the COVID pandemic.

| Data collection
The hospital medical records have been the basis of clinical features.
The data were entered into an electronic pattern. The considered independent factors of the studied population have been age, sex, antibiotics, either sensitivity or resistance to antibiotics, and hospitalization status. Supposing that the bacteria behavior about the evaluated antibiotics is independent, a weighted average was reported as overall monitored bacteria resistance to all evaluated antibiotics by the following equation:

| Statistical analysis
where R 1 stands for the antibiotic resistance of supposed isolated bacteria to first antibiotic and n 1 is the total sample number of the same isolated bacteria for which antibiogram test is reported for the first antibiotic. Moreover, R 2 stands for the antibiotic resistance of the same isolated bacteria to the second antibiotic, and n 2 is the total sample number of the same isolated bacteria for which the antibiogram test is reported for the second antibiotic. R n stands for the antibiotic resistance of the same isolated bacteria to the nth antibiotic and n n is the total sample number of the same isolated bacteria for which an antibiogram test is reported for the nth antibiotic. To establish an indicator to track changes in bacterial resistance patterns in light of the COVID-19  Table 1).
The urine samples contained the most specimens, followed by sputum, blood, wound, aspiration, pleural fluid and BAL, cerebrospinal fluid, and stool ( Table 2).
The most frequent Gram-negative and Gram-positive pathogens isolated in both years were Escherichia coli and Staphylococcus aureus specimens, respectively ( Table 3). The order of the most prevalent bacteria was E. coli, Pseudomonas aeruginosa, Staphylococcus strains, Klebsiella pneumonia, Citrobacter, and Acinetobacter baumannii (Table 3).
Gram-negative and -positive bacteria frequencies were 1329 and 112, respectively. E. coli, P. aeruginosa, and K. pneumonia were mainly detected from urine specimens. Moreover, Staphylococcus strains were predominant in blood and urine specimens. Furthermore, Citrobacter detection was more frequent in sputum specimens. A. baumannii was detected equally from sputum and blood specimens ( Enterobacter resistance has not had a significant increase, its resistance level was 100%, after the pandemic. Superficially, it might be interpreted that E. coli resistance has overall decreased. However, better scrutiny discloses that its resistance to gentamicin, cefepime, and cefotaxime has increased (Table 5).

| DISCUSSION
One of the future challenging public health issues as a subsequence of the COVID-19 pandemic may have been an increase in AMR caused by indiscriminative antibiotic use. To the best of our knowledge, this is the first study evaluating the COVID-19 pandemic's probable effect on AMR in Iran during the pandemic compared to prepandemic. Although there might be differences in the healthcare system set-up of each country. It shows an overall increase in AMR by the pandemic presence, which has been shown in some other countries, including India, 8 Mexico, 18 Indonesia, 10 Serbia, 11 and so forth. The current study showed an increase in resistance of Gramnegative bacteria (Supporting Information: Figure 1), P. aeruginosa, K.
pneumonia, A. baumannii, and Citrobacter, to most reported antibiotics by the pandemic presence, particularly in P. aeruginosa and K. pneumonia. A study in India on COVID-19 patients reported an increase in resistance of P. aeruginosa to fourth generation of cephalosporins, including cefepime. 8 The same research also notes a rise in ciprofloxacin and T A B L E 5 Comparison of some Gram-negative bacteria resistant to some antibiotics during prepandemic a and pandemic b periods of times. Note: Gram-positive bacteria have a far smaller reported sample size than Gram-negative bacteria. Although certain antibiotic use has increased dramatically in particular circumstances, the prevalence of Gram-positive bacteria as a whole is significantly declining ( Table 6).
Antibiotic not tested is indicated by *, ** chi-square. Gentamicin resistance in K. pneumoniae. Moreover, research conducted in Mexico found that both K. pneumonia and P. aeruginosa were becoming more resistant to cefepime, ciprofloxacin, and gentamicin. 18 A recent study in Northeast Iran focusing on E. coli, P. aeruginosa, K.
pneumonia, and A. baumannii strains showed a significant rise in resistance rate during 2020-2022. For instance, a 30% increase in K.
pneumonia to cefotaxime is reported. 21 Gram-negative bacteria, specifically K. pneumoniae, are one of the main reasons for VAP in the intensive care units (ICU). 22 On the other hand, the COVID-19 pandemic had overwhelmed ICU admission due to respiratory failure.
Prophylactic empirical prescription of antibiotics to control the threat of bacterial co-infection led to an increase in AMR. 23 Even though the risk of co-infection was low, 70% of admitted COVID-19 patients in Bangladesh received prophylactic antibiotics, according to a study. Long hospitalization and use of medical devices in the ICU, lack of effective surveillance, and immunocompromised patients due to corticosteroid prescription all contributed to an increase in hospital-acquired Infection. 24 Even more, the laboratory tests were in shortage 23 and nurse numbers were not in proportion to the patients, 25 which may lead to the empirical use of antibiotics concluded in AMR increase.
Remarkably, during the pandemic, A. baumannii resistance to all mentioned antibiotics has been 100%, albeit it was not a frequent microorganism. Likewise, but not at the same level, P. aeruginosa and Citrobacter have had more than 50% resistance to the same antibiotics. It seems that these might be the most challenging post-pandemic issues.
E. coli has different behavior in juxtaposition to other monitored The increasing Gram-positive bacteria' resistance to cephalexin may were caused by irrational overuse of it. 8 The prevalence of Gram-positive bacteria has decreased since COVID-19's presence. 26 Although the number of Gram-positive samples on which antibiogram tests were done in the current study has not been enough to distinguish a significant trend, the increase in Gram-positive pathogens' resistance specifically methicillin-resistance Staphylococcus aureus and vancomycin-resistance enterococcus must be a subject of a detailed study to be determined.
An increase in resistance to the cephalosporin third or fourth generation, such as ceftriaxone, cefotaxime, and cefepime (Supporting Information: Figures 1 and 2 writing-original draft.